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Aims: Introduction: Spinal fusion surgery is often associated with severe postoperative pain. This study aimed to determine whether intravenous acetaminophen produces equivalent analgesic effects to flurbiprofen under fentanyl patient-controlled analgesia (PCA) after one-level lumbar spinal fusion surgery. Study Design: Rondomized controlled trial. Place and Duration of Study: Department of Anesthesia, Nagasaki Rosai Hospital, Sasebo Japan, between October 2015 to March 2017. Methodology: We studied 75 patients who underwent one-level lumbar spinal fusion surgery. Patients were randomly allocated to 1 of 3 groups: Group A (n = 25), which received 15 mg/kg acetaminophen intravenously every 6 hr. Group F (n = 25), which received 1 mg/kg flurbiprofen intravenously every 8 hr; and Group C (n = 25), which received saline every 6 hr as the control. Each drug was started from prior to skin closure to 24 hr after surgery. All patients received fentanyl at a fixed dose of 0.33 μg/kg/hr continuously after a bolus administration of 250 μg fentanyl. A bolus of 0.33 μg/kg of fentanyl was administered on demand by PCA (lockout interval 15 min). Postoperative pain was evaluated using a numerical rating scale (NRS) at 1, 2, 6, 12, 24 hr postoperatively and fentanyl consumption was recorded for 6 and 24 hr after surgery. The frequency of bolus fentanyl administration were also recorded. Results: There were no significant differences in NRS scores among the 3 groups. Acetaminophen and flurbiprofen did not show opioid sparing-effects under fentanyl PCA. However, the frequency of fentanyl boluses were significantly less in group A than in group C. Conclusions: Acetaminophen may produce equivalent analgesic effects to flurbiprofen after one-level lumbar spinal fusion surgery.

Radiofrequency thermocoagulation of the cervical posterior medial branch is used for reducing chronic neck-shoulder pain and nape-back pain which derived from facet joints due to cervical spondylosis for a long period. The patients lie prone or supine according to the upper or the lower medial branch neurotomy. When the insulation needle is contacted in the target deep branches around the hollow of joint column under C-arm fluoroscopy, the radiating pain is obtained. The contraction of paravertebral muscle at 5 Hz and the radiating pain at 50 Hz could be verified. The best needle position in thermocoagulation is the point which the radiating pain is gotten by electrical stimulation with pulse width of 1 ms and low voltage of less than 0.5 V. Without the complications after radiograph with contrast medium and a 0.5 mL of 2% mepivacaine, the radiofrequency is performed by thermocoagulation at 60–90 °C for 90 s. The complications include temporary skin hypoesthesia, dorsal muscle power weakness, pain enhancement, and residual pain. Radiofrequency thermocoagulation of cervical posterior medial branch for chronic neck-shoulder pain is performed by neurolysis at 60-90 °C for 90-seconds on the target deep branches around the hollow of joint column under fluoroscopy.

We investigated the effect of low-dose droperidol on heart rate-corrected QT (QTc) interval and interaction with propofol. Seventy-two patients undergoing upper limb surgery were included in this study. Patients were randomly allocated to one of three groups: group S (n = 24), which received 1 ml saline; group D1 (n = 24), which received 1.25 mg droperidol; or group D2 (n = 24), which received 2.5 mg droperidol. One minute later, fentanyl (3 μg/kg) was administered. Two minutes after fentanyl administration, anesthesia was induced using propofol (1.5 mg/kg) and vecronium. Tracheal intubation was performed 3 min after the administration of propofol. Heart rate, mean arterial pressure, bispectral index, and QTc interval were recorded at the following time points: immediately before the droperidol injection (baseline); 3 min after the saline or droperidol injection; 3 min after the propofol injection; and 2 min after tracheal intubation. Compared to baseline, the QTc interval in group S and group D1 was significantly shorter after propofol injection, but recovered after tracheal intubation. In group D2, the QTc interval was significantly prolonged after droperidol injection, but recovered after propofol injection, and was significantly prolonged after tracheal intubation. We found that saline or 1.25 mg droperidol did not prolong QTc interval, whereas 2.5 mg droperidol prolonged the QTc interval significantly, and that propofol injection counteracted the prolongation of the QTc interval induced by 2.5 mg droperidol.

Tramcet is a mixture of tramadol and acetaminophen. Acetaminophen poisoning may be caused by excessive intake of Tramcet. A 17-year-old female took excessive quantity of Tramcet before noon. She reported it herself in the emergency room. Her main complaint was nausea and dizziness. Acetaminophen may cause liver damage with dose-dependent manner. Because there was a possibility of acetaminophen poisoning, we started oral acetylcysteine. She was discharged from hospital 5 days later without side effects of acetylecysteine and liver damage.

Patients undergoing extensive cervical spine surgery (ECSS) occasionally require emergency reintubation due to postoperative airway complications. To avoid it, an endotracheal tube is retained in patients maintained under sedation overnight. This study was conducted to determine whether dexmedetomidine would be superior in sedative effects to propofol for postoperative sedation after ECSS.We studied 32 consecutive patients undergoing ECSS who required prophylactic intubation postoperatively under sedation overnight. The patients were randomly divided into two groups. Group D (n = 16) received dexmedetomidine 0.1 μg/kg/min for 10 min as a loading dose, followed by a continuous infusion at 0.4 μg/kg/h. Group P (n = 16) received propofol 0.1 mg/kg/min for 10 min as a loading dose, followed by a continuous infusion at 1 mg/kg/h. All patients received analgesia with buprenorphine. Ramsay sedation scale, extremity movement, and pain intensity were recorded every 2 h. Dexmedetomidine and propofol dosages were adjusted to maintain a desired sedation level. Nursing staff adjusted dopamine to maintain systolic blood pressure100 mmHg and administered atropine when the heart rate was50 bpm.The proportions of adequate sedation level, movement, and pain status were similar between groups. In group D, heart rates were lower, frequency of atropine use was greater, and dopamine dose was higher than in group P.Both sedatives are efficacious after ECSS; however, dexmedetomidine decreased heart rate and required higher dose of dopamine.

SUMMARY The aim of this study was to determine the effect of thiamylal and propofol on heart rate-corrected QT (QTc) interval during anaesthetic induction. We studied 50 patients undergoing lumbar spine surgery. Patients were administered 3 microgxkg(-1) fentanyl and were randomly allocated to receive 5 mgxkg(-1) thiamylal or 1.5 mgxkg(-1) propofol as an induction agent. Tracheal intubation was performed after vecuronium administration. Heart rate, mean arterial pressure, bispectral index score, and 12-lead electrocardiogram were recorded at the following time points: just before (T1) and 2 min after (T2) fentanyl administration; 2 min after anaesthetic administration (T3); 2.5 min after vecuronium injection (T4); and 2 min after intubation (T5). Thiamylal prolonged (p < 0.0001), but propofol shortened (p < 0.0001), the QTc interval.

悪性高熱症 (MH) の3家系を経験した. A家系: 35歳, 男性. MHの既往歴あり. 上腕骨骨折手術を全静脈麻酔で行った. 患者と父親にCICR速度亢進とRYR1遺伝子変異, 弟らにも同様の変異を認めた. 弟の娘の鼠径ヘルニア根治術も全静脈麻酔で行った. B家系: 66歳, 男性. MHの既往歴あり. 腰部椎間板ヘルニア手術を脊髄くも膜下硬膜外併用麻酔で行った. 患者と長男にCICR速度亢進を認めた. C家系: 75歳, 男性. MHで死亡の家族歴あり. CICR速度の亢進は患者では認めず, 妻, 次女らに認めた. S状結腸癌手術は全静脈麻酔で行った. MH素因者には診断確定が望まれ, MH患者に準じた麻酔を行うべきである.

Background and objectiveThis study was carried out to clarify the effect of the combination of acute hypervolaemic haemodilution and hypotensive anaesthesia induced with sevoflurane on human middle cerebral artery flow velocity using transcranial Doppler ultrasonography.MethodsThirty patients who were maintained with N2O–O2–sevoflurane anaesthesia undergoing hip surgery were randomly divided into two groups (no controlled hypotension group, Group A, and controlled hypotension group, Group B). Haemodilution was produced by acute preoperative infusion of 1000 mL of hydroxyethylstarch without removing blood in both groups. Mean arterial pressure was maintained at approximately 95 mmHg in Group A and at 55 mmHg for 80 min by increasing the inspired concentration of sevoflurane in Group B. Middle cerebral artery flow velocity was measured before haemodilution, after haemodilution, 80 min after starting hypotension, and 60 min after recovery from hypotension.ResultsMiddle cerebral artery flow velocity significantly increased in both groups after haemodilution; by 28%, in Group A, P < 0.05 vs. before haemodilution and by 30% vs. before haemodilution in Group B, P < 0.05). During controlled hypotension, it decreased towards the pre-haemodilution value (P < 0.05 vs. after haemodilution).ConclusionsSevoflurane-induced hypotension to a mean arterial pressure of 55 mmHg would reduce middle cerebral artery flow that had been increased by acute hypervolaemic haemodilution, such as haematocrit value of 26%, whereas it could preserve the flow in pre-haemodilution condition during normocapnia.

This study was performed to determine the prevalence and the prognostic significance of microalbuminuria in patients admitted to intensive care unit (ICU) after spontaneous intracerebral hemorrhage (ICH). From May 2004 to April 2006, we studied 59 consecutive ICH patients verified using computed tomography and admitted to our ICU within a day after stroke. General clinical, neurologic data, and Glasgow Coma Scale (GCS) were recorded at admission to ICU. Urine was collected at admission to ICU for measuring the urinary microalbumin/creatinine ratio. At hospital discharge, neurologic outcome was assessed using Glasgow Outcome Scale. Among 59 patients, 37 (63%) had unfavorable neurologic outcomes (death, persistent vegetative state, and severe disability). The prevalence rate of microalbuminuria was 85% [95% confidence interval (CI), 76-94]. The areas under the receiver operator characteristic curves showed that the urinary microalbumin/creatinine ratio [0.81 (95% CI, 0.70-0.92)] and the GCS score [0.78 (95% CI, 0.66-0.90)] at admission were significant predictors of unfavorable neurologic outcome at hospital discharge. The threshold value, sensitivity, specificity, and likelihood ratio for the urinary microalbumin/creatinine ratio were 200 mg/g, 51% (95% CI, 39-64), 96% (95% CI, 90-100), and 11.3 (95% CI, 7.9-16.0); and those for the GCS score were 11, 46% (95% CI, 36-61), 96% (95% CI, 90-100), and 10.1 (95% CI, 7.2-14.1), respectively. This study confirmed a high prevalence of microalbuminuria in ICH patients in ICU, and suggested that the urinary microalbumin/creatinine ratio >200 mg/g was comparable to the GCS score

Non-invasive positive pressure ventilation (NPPV) reduces the incidences of ventilator-associated pneumonia, the duration of ICU stay and the mortality rate compared with conventional respiratory management of the patients with acute respiratory failure (ARF). Recently, helmet NPPV equipment became available. Because of the high tolerability, the helmet seems to be the best NPPV interface when prolonged and continuous assistance is needed. In this study, we analyzed several factors related to failure of helmet NPPV in ARF patients in intensive care unit (ICU), retrospectively.Institutional Research Committee of Nagasaki Rosai Hospital approved this study. We studied consecutive patients with ARF who needed ventilator support in ICU from February 2012 to February 2013. We excluded the patients whose trachea had been intubated before admission to ICU and comatose patients. After admission to ICU, all ARF-patients received helmet NPPV and conventional intensive care therapy including sedation with dexmedetomidine and vasoactive agents. General clinical data including blood gas analysis were recorded at admission to ICU and during ICU stay. Patient's tracheas were intubated if they met at least one of the following criteria, as judged after they had received helmet NPPV: lack of improvement in arterial blood pH or PaCO2; changes in mental status, in patients unable to tolerate noninvasive ventilation; a decrease in SaO2 to less than 85% despite the use of a high FIO2. The final decision of endotracheal intubation was made by a staff intensivist. We defined the failure of helmet NPPV as the execution of endotracheal intubation. The data were presented as median (IQR), and statistical analysis was performed using Mann-Whitney U-test and Fisher's exact probability test at the P0.05 level of significance.The subjects were 36 patients (25 males and 11 females) aged 27 to 94 years, including 6 patients with acute heart failure (AHF), 8 with pneumonia, 6 with aspiration pneumonia, 2 with hemothorax, 10 with acute respiratory distress syndrome (ARDS), 1 with asthma, and 3 with acute exacerbation of chronic obstructive pulmonary disease (COPD). NPPV was successful in 29 (19 males and 10 females), but unsuccessful in 7 patients (6 males and 1 female). There were no significant differences in demographic data and the variables before induction of NPPV between the successful and unsuccessful groups. The P/F ratio was improved from 133 (99,167) to 209 (143,274) in the successful group, and from 93 (81,157) to 188 (129,271) in the unsuccessful group after the induction of NPPV, but there was no significant difference between the two groups. In the patients with unsuccessful NPPV, expiratory positive airway pressure, inspiratory positive airway pressure, respiratory rate, body temperature and FIO2 before removing NPPV were significantly higher, and ICU stay was longer compared with the patients with successful NPPV. Furthermore, marked excretion of sputum was observed in 4 of the 7 patients with unsuccessful NPPV.Helmet NPPV improved oxygenation in ARF patients immediately after induction of NPPV. Although there were no significant predictable parameters of unsuccessful NPPV before induction of NPPV, a lot of excretion of sputum might be suggested as a risk factor.

To determine the prevalence and the prognostic significance of microalbuminuria in patients after aneurysmal subarachnoid hemorrhage (SAH). Prospective and observational clinical study. Multidisciplinary intensive care unit. Fifty-one consecutive patients who underwent aneurysm clipping or endovascular surgery after SAH; 8 patients who underwent surgical clipping for unruptured intracerebral aneurysm served as control. None. General clinical and neurological data were recorded on admission. Urine was collected preoperatively and daily for up to 7 days postoperatively for measuring the urinary microalbumin/creatinine ratio. The Glasgow Coma Scale (GCS) score was also determined on admission and daily for up to 7 days after operation. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at 3 months after stroke. The prevalence rates of microalbuminuria were 74.5% in SAH and 37.5% in the control. Among the 51 patients, 25 had unfavorable neurological outcome (GOS 1–3). The areas under the receiver operator characteristic curves showed that the highest urinary microalbumin/creatinine ratio and the lowest GCS score during the first 8 days were the significant predictors of unfavorable neurological outcome. The threshold value, sensitivity, specificity, and likelihood ratio for the highest urinary microalbumin/creatinine ratio were 200 mg/g, 60% [95% confidence interval (CI) 41–79], 96% (95% CI 88–100), and 15.6 (95% CI 9.1–26.7), respectively. This study confirms a high prevalence of microalbuminuria in the SAH patients, and it suggests that the highest urinary microalbumin/creatinine ratio > 200 mg/g during the first 8 days is a significant predictor of unfavorable neurological outcome.

Study Objectives To evaluate the effect of preadministration of flurbiprofen on the plasma concentrations of prostaglandin E2 (PGE2) and postoperative pain. Design Prospective, randomized, controlled and double-blind study. Setting Inpatient surgery at Nagasaki Rosai Hospital. Patients 32 ASA physical status I to II patients scheduled for total knee arthroplasty or open anterior cruciate ligament reconstruction. Interventions Patients were randomly assigned to two groups. Five minutes before tourniquet inflation (350 mmHg), group A (n = 16) received placebo (intralipid, one mL · kg −1 ), and group B (n = 16) received flurbiprofen one mg · kg −1 IV. Catheters were placed in the ipsilateral femoral vein for collection of local blood and in a cubital vein for sampling of systemic blood. Measurements Prostaglandin E2 (femoral vein and cubital vein) was measured before tourniquet inflation (T1), before tourniquet deflation (T2), and immediately after tourniquet deflation (T3). Postoperative analgesia was provided with intravenous buprenorphine, 0.1 mg, on patient demand. Pain (Visual Analog Scale) was assessed at 0.5, one, two, 4, 6, 12 and 24 hours after surgery. Main Results Visual Analog Scale and buprenorphine consumptions in group B were significantly lower than those in group A during the first 4 postoperative hours. In group A, PGE2 in femoral vein increased significantly at T2 (359 ± 105 pg mL −1 , P −1 ) and returned to control values at T3 (252 ± 77 pg mL −1 ), whereas PGE2 in the cubital vein showed no change. In group B, PGE2 in either the femoral vein or cubital vein showed no change throughout the time course. Conclusions Preadministration of flurbiprofen suppresses the local production of PGE2 during tourniquet ischemia, resulting in reduced early postoperative pain in patients undergoing knee surgery.

Droperidol is an effective antiemetic, but its use is limited because of the warning of drug-induced QT prolongation. Some reports showed that low-dose droperidol does not significantly probing QT interval. This study was aimed to determine the effect of low-dose droperidol (1.25 and 2.5 mg) on QTc interval, and the interaction among droperidol, propofol and sevoflurane.Patients received either 1.25 mg (group L : n = 25) or 2.5 mg (group H : n = 25) droperidol, and fentanyl (3 μg x kg(-1)) was administered 2.5 min later. One minute after fentanyl administration, anesthesia was induced using propofol (1.5 mg x kg(-1)) and vecuronium. One minute after propofol administration, sevoflurane (3%) was started. Tracheal intubation was performed 3 min after propofol administration, and then sevoflurane was reduced to 1%.Compared to baseline, the QTc interval in group L was unchanged by droperidol. In group H, the QTc interval was significantly prolonged after droperidol injection, but recovered after propofol injection. After tracheal intubation, QTc interval was significantly prolonged in both groups.Droperidol's effect on QTc prolongation was shown at the dose of 2.5 mg but not 1.25 mg. This prolongation effect was offset by propofol, and was unchanged by sevoflurane.

Aim: This study was carried out to determine the dose–response relationship of the effects of prostaglandin E1 (PGE1) on the nerve root blood flow and the neurologic symptoms after lumbar decompressive surgery using laser Doppler flowmetry. Methods: Fifty-four patients undergoing lumbar laminectomy were randomly assigned to one of three groups. Each group received intravenously one of three test solutions; 10 ml of saline in group A (N = 18), 10 ml of saline containing PGE1, 20 μg, in group B (N = 18), and 10 ml of saline containing PGE1, 50 μg, in group C (N = 18). After lumbar laminectomy, a probe of laser Doppler flowmetry was placed directly on the lumbar nerve root. Nerve root blood flow (RBF) velocity was measured before the injection of test solution (T1), at 5 min (T2) and 10 min (T3) after starting injection, and 10 min after the end of injection (T4). A visual analogue scale (VAS) and the walking distance were measured for assessment of neurologic symptoms before and after surgery. Resu...

Background and objectives: It is known that ropivacaine produces a differential block for sensory and motor nerves with lower toxic potential than bupivacaine. This study was carried out to evaluate the comparative efficacy of ropivacaine and bupivacaine for lumbar epidural block in 16 outpatients with degenerative spinal disease. Methods: The study was performed in a prospective, randomized, double blind and crossover fashion. A single injection of 8 ml of 0.375% or 0.2% ropivacaine or 0.25% bupivacaine was given at the L4-5 interspace. Each subject received all of the test solutions at an interval of one week or more. The upper level of analgesia, pain and motor blockade were evaluated by pin prick, visual analogue scale (VAS), and Bromage scale, respectively, and the recovery times to mobilization, ambulation and spontaneous micturition were measured. Results: There was no significant difference in the upper level of analgesia and the reduction of VAS among the three trials. Bromage scale with...

Study Objective To evaluate the effects of controlled hypotension combined with hemodilution on human middle cerebral artery flow velocity (Vmca) by transcranial Doppler ultrasonography. Design Randomized prospective study. Setting Inpatient surgery at Nagasaki Rosai Hospital. Patients Thirty American Society of Anesthesiologists physical status I and II patients scheduled for total hip arthroplasty. Interventions Anesthesia was maintained with nitrous oxide–oxygen (N 2 O-O 2 ) and sevoflurane during normocapnia. Hemodilution was carried out after induction of anesthesia, in which blood was withdrawn then replaced with the same amount of hydroxyethyl starch to achieve a final hematocrit level of 32% (group A=mild hemodilution group, N=15) or 24% (group B=moderate hemodilution group, N=15). In both groups, controlled hypotension was induced with prostaglandin E 1 to maintain mean arterial pressure at approximately 55 mm Hg for 80 minutes. Measurements and Main Results Vmca and blood gas were measured before hemodilution, after hemodilution, 80 minutes after starting hypotension, and 60 minutes after recovery from hypotension. Vmca significantly increased in group A (+122%) and group B (+156%) after each hemodilution. In group B, Vmca was significantly greater than baseline values at 80 minutes after starting hypotension (+135%) and 60 minutes after recovery from hypotension (+140%). Conclusion The combination of moderate hemodilution, such as hematocrit value of 24%, and prostaglandin E 1 –induced hypotension would not impair middle cerebral artery flow during sevoflurane–N 2 O-O 2 anesthesia during normocapnia.

Among some kinds of cervical spine surgeries, combined anterior-posterior cervical spine surgery (CAP-CS surgery) requires prolonged operative time and highly invasive procedure. This study was performed to determine whether CAP-CS surgery was associated with increased risk of emergency airway management compared with other cervical spine surgeries (O-CS surgeries). The records of the patients who underwent cervical spine surgery between July 2001 and March 2003 at our institution were reviewed retrospectively, and we determined whether the CAP-CS surgery was associated with an increased risk of emergency airway management in comparison with O-CS surgeries, using the logistic regression analysis. A total of 165 were eligible for inclusion in the study. A total of 127, 20, 11, 5, and 2 patients suffered from cervical myelopathy, traumatic cervical spinal cord injury, atlantoaxial dislocation, cervical spinal tumors, and cervical pyogenic spondylitis, respectively. The operative approaches were CAP-CS surgery, anterior surgery, posterior surgery, and atlantoaxial surgery in 10, 56, 88, and 11 patients, respectively. Thus, the operative approaches were CAP-CS surgery in 10 patients and O-CS surgeries in 155 patients. Postoperative emergency airway management was required in 7 of the 10 patients (70%) who underwent CAP-CS surgery, and 2 of the 155 patients (1%) who underwent O-CS surgeries. The increased risk of postoperative emergency airway management imposed by CAP-CS surgery was 178.5 by an odds ratio, with a 95% confidence interval of 25.6 to 1246. The results show that CAP-CS surgery provides a major risk factor for postoperative emergency airway management.

Tracheal intubation using a lightwand device (Trachlight) should minimize hemodynamic change by avoiding direct-vision laryngoscopy. We evaluated hemodynamic and catecholamine responses during tracheal intubation using a Trachlight in elderly patients with hypertension.Twenty-six hypertensive patients aged over 65 years undergoing orthopedic surgery were randomly divided into two groups, group L (n = 13) and group T (n = 13). Anesthesia was induced with fentanyl (2 microg x kg(-1)) and propofol (1.5 mg x kg(-1)), and then muscle relaxation was obtained with vecuronium (0.15 mg x kg(-1)). The trachea was intubated with either a Macintosh laryngoscope (group L) or a Trachlight (group T). Hemodynamics, plasma catecholamine concentrations, and arterial blood gases were measured before the induction of anesthesia (T0), before tracheal intubation (T1), immediately after tracheal intubation (T2), and 3 min after tracheal intubation (T3).The intubation time was shorter in group T than in group L (12.6 +/- 1.7 vs 23.5 +/- 2.9 s, mean +/- SE; P0.01). Compared with the preinduction (T0) value, systolic blood pressure (SBP) showed a significant decrease at T1 and T3 in group L and at T1, T2, and T3 in group T. The heart rate (HR) and plasma norepinephrine (NE) concentration showed no change in either group throughout the time course, whereas the plasma epinephrine (E) concentration showed a significant decrease at T2 and T3 in both groups. The mean values of the rate-pressure product (RPP: HR x SBP) were less than 15000 after tracheal intubation in both groups. There was no significant difference in hemodynamic or catecholamine responses between groups at any point. No patient had ischemic ST-T changes in either group.A lightwand has no advantage over a laryngoscope in terms of hemodynamic and plasma catecholamine responses to tracheal intubation in elderly patients with hypertension, despite a shorter intubation time.

大腿骨頸部骨折に対する骨接合術を脊椎麻酔管理下に施行した400名の高齢者(65～97歳)における術前,術中,術後合併症について検討した.ネオペルカミンS®にて全症例ともTh10以下の無痛域を得た.術前合併症では高血圧をはじめとする循環器系障害が最も多かった.術中合併症では低血圧や経皮的酸素分圧低下の発生が多かった.術後に心筋梗塞および脳硬塞の再発や発症,術前腎機能の一過性増悪症例を認めた.典型的な深部静脈血栓症はなかったが,肺梗塞発生症例がみられた.死亡症例は2症例であった.高齢者では術前合併症の有無にかかわらず,臓器機能予備力の正確な把握とともに術中血行動態の維持が最も重要と思われ,同時に,微小血栓・塞栓症に対する早期診断が必要である.

The present study was designed to evaluate the effects of clonidine on human middle cerebral artery flow velocity and the cerebrovascular CO2 response during sevoflurane anesthesia using transcranial Doppler ultrasonography. The subjects were nine awake volunteers (group A) and 18 patients receiving oral preanesthetic medication of clonidine, 3-4 mcg/kg, (group C), or placebo (group S). In groups C and S, anesthesia was induced with inhalation of sevoflurane-nitrous oxide. After tracheal intubation, anesthesia was maintained with 2% end-tidal sevoflurane alone. In group A, each volunteer wore a nose clip and breathed through a mouthpiece using a Mapleson D breathing system. The time-mean middle cerebral artery flow velocity (Vmca) was measured during hypocapnia, normocapnia, and hypercapnia. In groups S and C, the Vmca values were significantly lower than those of group A at each PaCO2 level. The Vmca value of group C was significantly lower than that of group S in hypercapnia, but not in hypocapnia or normocapnia. The CO2 response slope of group C was significantly lower than those of groups A and S. The results indicate that clonidine, administered as an oral preanesthetic medication, reduces Vmca in hypercapnia but not in hypocapnia or normocapnia, and reduces the cerebrovascular CO2 response during sevoflurane anesthesia.

The effects of controlled hypotension induced with trimethaphan (TMP), nitroglycerin (TNG) or prostaglandin E1 (PGE1) during sevoflurane anaesthesia on hepatic function were studied in 28 patients undergoing spinal fusion surgery. Patients were randomly divided into three groups to receive TMP (group A, n = 10), TNG (group B, n = 10) or PGE1 (group C, n = 8). Anaesthesia was maintained with N2O and sevoflurane. The mean arterial blood pressure was maintained at 60 mmHg for 90 min. Measurements included arterial ketone body ratio (AKBR-acetoacetate/3-hydroxybutyrate), SGOT, SGPT, LDH, blood glucose and blood gases were made. Measurements were taken before hypotension, 60 min and 90 min after starting hypotension, 60 min after recovery from hypotension and on the post-operative day. AKBR showed no significant change. SGOT, SGPT and LDH were within normal limits. Controlled hypotension induced with TMP, TNG or PGE1 under sevoflurane anaesthesia in surgical patients did not cause hepatocellular damage.

超高齢者の腰椎麻酔下手術時にプロポフォールを持続投与し,至適鎮静を得るために必要な投与量が呼吸•循環動態に及ぼす影響を検討した.前投薬としてジアゼパム5mgを筋注した80歳以上の超高齢者を対象とし,Th10以下に麻酔域を固定した.術中のプロポフォール投与量を至適鎮静度(Ramsay Score 2～4)を維持するように調節した.至適鎮静度維持のためのプロポフォール持続投与量は手術開始15分後,30分後でそれぞれ0.52±α07mg/kg/hr, 0.72±0.16mg/kg/hrであった.この間,血圧,心拍数,血液ガス,呼吸数は,投与前値に比し有意な変化を示さなかった.超高齢者の腰椎麻酔下手術時の鎮静薬としてプロポフォールの少量持続投与は呼吸•循環動態に対して安全に使用しうることが示唆された.

This study was carried out to evaluate the therapeutic effect of epidural steroid injection on pseudoclaudication in patients with lumbar degenerative spinal canal stenosis.Fifty-three patients who complained of pseudoclaudication of less than 20 m in walking distance were randomly divided into three groups. Group 1 (n = 16) underwent epidural injection with 8 ml of saline. Group 2 (n = 18) underwent epidural block with 8 ml of 1% mepivacaine. Group 3 (n = 19) underwent epidural block with a combination of 8 ml of 1% mepivacaine and 40 mg of methylprednisolone. The criteria of evaluation were as follows: excellent effect,100 m in walking distance; good effect, 20-100 m in walking distance; poor effect,20 m in walking distance.In group 1, the numbers of patients who showed a good effect were two (12.5%) after 1 week, one (6.5%) after 1 month, and one (6.5%) after 3 months. In group 2, the numbers of patients who showed a good or excellent result were 10 (55.5%) after 1 week, three (16.7%) after 1 month, and one (5.6%) after 3 months. In group 3, the numbers of patients who showed a good or excellent result were 12 (63.2%) after 1 week, three (15.8%) after 1 month, and one (5.3%) after 3 months. There was no significant difference in the effectiveness of treatment between group 2 and group 3 throughout the time course.The results suggest that epidural steroid injection has no beneficial effect on the pseudoclaudication associated with spinal canal stenosis as compared with epidural block with a local anesthetic alone.

人工股関節手術を受けるASAリスクI,IIの成人男女で肝腎機能障害のない36名を,貯血および回収血による自己血輸血量により1,000ml未満輸血群(L群:200～800ml,平均680ml)15名と,1,000ml以上輸血群(H群:1,000～1,800ml,平均1,174ml)21名の2群に分け,輸血前および輸血後1日目の血清総ヘモグロビン濃度,遊離ヘモグロビン濃度,総ハプトグロビン濃度,総ビリルビン濃度を測定した.2群とも輸血前後では総ビリルビン濃度にのみ有意差を認め,両群間に有意差を認めなかった.遊離ヘモグロビンは輸血後,H群の1名のみに検出された.今回行なわれた1,000ml以上(1,000～1,800ml)の自己血輸血量は,血清遊離ヘモグロビン濃度に影響を与えなかった.

The effects of acute haemodilution, during prostaglandin E1 (PGE1)-induced hypotension, on the blood coagulation-fibrinolysis system were studied in 40 patients undergoing hip surgery. The patients were randomly divided into four groups of 10 patients each; Group A (control) received no induced hypotension or haemodilution, group B received hypotension alone, group C received haemodilution alone and group D received the combination of induced hypotension and haemodilution. Haemodilution in groups C and D was produced by drawing approximately 1000 mL of blood and replacing it with the same amount of 6% hydroxyethyl starch. Induced hypotension in groups B and D was conducted with PGE1 and mean blood pressure was maintained at 55 mmHg. The mean dosage of PGE1 was 648 micrograms in group B and 661 micrograms in group D. In the control and PGE1-induced hypotension groups there was no significant change in platelet count (PLT), prothrombin time (PT), activated partial thromoplastin time (aPTT), fibrinogen (FIB), antithrombin-III (AT-III) or plasminogen (PLG). Haemodilution alone caused significant decreases in PLT (-43%), PT (+21%), FIB (-33%), AT-III (-21%) and PLG (-27%), and a significant increase in aPTT (+26%), whereas the combination of PGE1-induced hypotension did not cause any further change in these parameters. Serum-fibrin degradation products (FDP) significantly increased (+300%) and PLG significantly decreased (-30%) after surgery in all groups. It can be concluded that acute haemodilution to a haematocrit value of 22 +/- 2% causes a slight coagulopathy, which is not enhanced when combined with PGE1-induced hypotension.

Combined effects of prolonged prostaglandin E1 (PGE1)-induced hypotension and haemodilution on hepatic function were studied in 30 patients undergoing hip surgery. The patients were randomly allocated to one of three groups; those in group A (n = 10) were subjected to controlled hypotension alone, those in group B (n = 10) to haemodilution alone and those in group C (n = 10) to both controlled hypotension and haemodilution. Haemodilution in groups B and C was produced by withdrawing approximately 1000 mL of blood and replacing it with the same amount of dextran solution, and final haematocrit values were 21 or 22%. Controlled hypotension in groups A and C was induced with PGE1 to maintain mean arterial blood pressure at 55 mmHg for 180 min. Measurements included arterial ketone body ratio (AKBR, aceto-acetate/3-hydroxybutyrate) and clinical hepatic function parameters. AKBR and biological hepatic function tests showed no change throughout the time course in groups A and B. In group C, AKBR showed a significant decrease at 120 min (-40%) and at 180 min (-49%) after the start of hypotension and at 60 min (-32%) after recovery of normotension, and SGOT, SGPT, LDH and total bilirubin showed significant increases after operation. The results suggest that a prolonged combination of more than 120 min of PGE1-induced hypotension and moderate haemodilution would cause impairment of hepatic function.

We evaluated whether preadministration of low-dose ketamine could attenuate tourniquet pain and arterial pressure increase using high tourniquet pressure in ten healthy awake volunteers. Ketamine, 0.1 mg x kg(-1), or normal saline was given intravenously in a double-blind fashion before tourniquet inflation with a pressure of 400 mmHg at the thigh. Visual analog scale (VAS) scores and systolic blood pressure (SBP) were measured at 5-min intervals. Ketamine significantly reduced VAS scores compared to saline just after tourniquet inflation [90 (64-100) mm, median (range), with saline versus 66 (50-81) mm with ketamine, P0.01] and at 30 min [92 (61-100) mm with saline versus 70 (50-100) mm with ketamine, P0.03), and significantly prolonged tourniquet time (28 +/- 6 min with saline, mean +/- SD, versus 37 +/- 7 min with ketamine, P0.01). SBP (120 +/- 9 mmHg) significantly increased before tourniquet deflation (133 +/- 16 mmHg) in the saline trial, but not in the ketamine trial. The results show that preadministration of low-dose ketamine attenuates tourniquet pain and arterial pressure increase during high-pressure tourniquet application and prolongs tourniquet time in healthy volunteers.

症例は47歳, 男性. 頸椎神経根性疼痛の治療目的で星状神経節ブロック (stellate ganglion block ; SGB) を行った. 患者にSGBに関する説明を行い承諾を得た後, 血液凝固能検査で異常のないことを確認した. SGB施行1時間後までは問題なく経過し帰宅したが, その後に呼吸困難を訴えたため緊急入院となった. 頸部血腫の診断のもと, 緊急止血・血腫除去術が施行された. その後の経過は良好であったが, SGBによる一連の経過に対してクレームが発生した. 1年半にわたる話し合いの末, 示談となった.

Background This study was designed to evaluate the effects of sevoflurane with and without nitrous oxide on human middle cerebral artery (MCA) flow velocity, cerebrovascular carbon dioxide reactivity, and autoregulation compared with the awake state using transcranial Doppler ultrasonography. Methods In 14 patients, the time-mean middle cerebral artery flow velocity (Vmca) was measured when the end-tidal carbon dioxide level was approximately 30, 40, and 50 mmHg under the following conditions: (1) awake; (2) with 2% (1.2 MAC) sevoflurane; and (3) with 1.2 MAC sevoflurane-60% nitrous oxide. In six other patients, the cerebrovascular autoregulation during anesthesia was determined using intravenous phenylephrine to increase blood pressure. Results Sevoflurane (1.2 MAC) significantly decreased Vmca compared with the awake value at each level of end-tidal carbon dioxide, whereas 1.2 MAC sevoflurane-60% nitrous oxide did not exert significant influence. The Vmca in normocapnic patients decreased from 69 cm/s to 55 cm/s with 1.2 MAC sevoflurane and then increased to 70 cm/s when nitrous oxide was added. Sevoflurane (1.2 MAC) with and without 60% nitrous oxide had a negligible effect on cerebrovascular carbon dioxide reactivity. A phenylephrine-induced increase of mean arterial pressure did not influence Vmca during anesthesia. Conclusions Sevoflurane (1.2 MAC) reduced Vmca compared with the awake condition, whereas the addition of nitrous oxide caused Vmca to increase toward the values obtained in the awake condition. The cerebrovascular carbon dioxide reactivity and autoregulation were well maintained during 1.2 MAC sevoflurane with and without 60% nitrous oxide.

There have been conflicting reports on whether propofol prolongs, shortens, or does not change QT interval. The aim of this study was to determine the effect of target-controlled infusion (TCI) of propofol on heart rate-corrected QT (QTc) interval during anesthetic induction. We examined 50 patients undergoing lumbar spine surgery. Patients received 3 μg/kg of fentanyl and were randomly allocated to one of the following 2 groups. Group S patients received 5 mg/kg of thiamylal followed by sevoflurane, 5 % at the inhaled concentration. Group P patients received propofol using TCI system at 5 μg/mL for 2 min followed by 3 μg/mL. Tracheal intubation was performed after vecuronium administration. Heart rate (HR), mean arterial pressure (MAP), bispectral index score (BIS), and QTc interval in 12-lead electrocardiogram were recorded at the following time points: just before fentanyl administration (T1), 2 min after fentanyl injection (T2), 1 min after thiamylal injection or 2 min after the start of TCI (T3), just before intubation (T4), and 2 min after intubation (T5). BIS and MAP significantly decreased after anesthetic induction in both groups. HR decreased after anesthetic induction and recovered after tracheal intubation in group P, whereas it did changed in group S throughout the study period. QTc interval was shortened at T3 and T4 in group P, but prolonged at T3, T4, and T5 in group S, as compared with T1. Propofol TCI shortens QTc interval, whereas sevoflurane prolongs QTc interval during anesthetic induction.

股関節全置換術において,同種血輸血を回避する目的で,希釈式自己血輸血(Hct 24%)に低血圧麻酔(プロスタグランジンPGE1で収縮期圧75mmHgを約70分間維持)を併用した場合の安全性を検討するために,術後における血液検査ならびに臨床状態の面から非希釈式自己血輸血(貯血式・回収式,Hct 31%)に低血圧麻酔を併用した場合と比較した。両群とも同種血輸血は必要としなかった。貧血は希釈式群では術後4週目に,非希釈式群では3週目に正常下限域値に回復した。血液生化学における肝腎機能検査では,両群とも術後異常値を示さなかった。希釈式群において術後貧血のため創部治癒が遷延した例や血栓性静脈炎等の合併症のためにリハビリのスケジュールが遅延した例はなく,退院までの日数も両群で差はなかった。以上より,本法は同種血輸血を回避するための手段として臨床上有用と考えられる。

股関節全置換術において,中等度血液希釈下(Hct 23%)でプロスタグランディン(PGE1)による収縮期圧75mmHgの低血圧麻酔を約1時間併用した際の肝細胞および腎尿細管細胞機能に及ぼす影響を,動脈血中ケトン体比(AKBR)と尿中NAG排泄量(NAG-index)を指標として,軽度血液希釈下(Hct 31%)の場合と比較検討した。AKBRは血液希釈後,低血圧中・中止後,術後とも脱血前(対照値)および軽度希釈下と差はなかった。NAG-indexは低血圧中止後～術後で対照値より有意に増加し,術後は軽度希釈下との間にも差が認められた。術後の血液生化学検査では肝・腎機能とも異常値は示さなかった。以上より,中等度血液希釈下でPGE1による低血圧麻酔を併用した場合,術後一過性の腎尿細管細胞障害が出現し注意を要するが,肝・腎機能における臨床的な後遺症は残さなかった。

The present study was conducted to determine the relationship between magnesium concentration in cerebrospinal fluid (CSF) and delayed cerebral ischemia (DCI) in patients with subarachnoid hemorrhage (SAH).We studied 39 consecutive patients undergoing surgery after SAH. A spinal drainage catheter was inserted into the lower lumbar vertebrae before surgery. CSF was then sampled and the magnesium concentration measured. General clinical data, Hunt-Hess (H-H) grade and Fisher grade, aneurysm size and site, intracerebral and intraventricular hemorrhage, and blood glucose levels were all recorded on admission. At the same time, the Glasgow coma scale (GCS) score was calculated. Outcomes were assessed using the Glasgow outcome scale at discharge. DCI was defined as a two-point decrease in the GCS score and/or focal deficit, and was confirmed by cerebral angiography. The recorded values were expressed as the median (interquartile range).Of the 39 patients, 23 (59%) had DCI. The magnesium concentration in the DCI cases was 2.8 (2.7 and 2.9) mg x dl(-1), which was significantly lower than that in the non-DCI cases, i. e., 2.9 (2.8 and 3.0) mg x dl(-1) (P0.05). There were no significant differences in the other factors.The results indicate that preoperative hypomagnesemia within the CSF might play a role in the development of DCI in patients with SAH; however, further studies will be necessary to confirm this observation.

Study Objectives: To describe a method of the authors' design for estimating gastric volume quantitatively using ultrasound and to evaluate the usefulness of this method in the clinical setting. Design: Prospective, two-phase clinical study. Setting: University hospital. Patients and volunteers: Phase 1 study: 31 patients who were undergoing general anesthesia and had no gastrointestinal disorder. Phase 2 study: 8 healthy volunteers. Interventions: With each subject in the sitting position, a cross-sectional view of the stomach was obtained via ultrasound along the median line of the epigastric region. The cross-sectional area of the stomach (CSA) was measured by the analysis unit on the basis of the trace-enclosure method, and a mean value was obtained from triplicate measurements. Measurements and Main Results: In the phase 1 study, CSA was measured after the patient had fasted for 1 hour, 4 hours, and more than 8 hours. CSA (cm 2 ) was 19.2 ± 0.9 cm 2 at 1 hour, 11.0 ± 0.7 cm 2 at 4 hours, and 5.5 ± 0.4 cm 2 at more than 8 hours. That is, CSA significantly decreased as fasting time was prolonged ( p vs. more than 8 hours and 4 hours vs. more than 8 hours). Most of the patients (87%) who fasted for more than 8 hours had a CSA less than 8.0 cm 2 . In the phase 2 study, after patients had fasted for more than 8 hours, CSA was measured both before and 5 minutes after the patient drank 50 ml of milk. CSA was 5.0 ± 0.5 cm 2 before and 8.5 ± 0.9 cm 2 after ingestion of the milk ( p 2 before drinking the milk, whereas only 2 of 8 patients had a CSA less than 8.0 cm 2 after. Conclusions: This method would be useful to estimate gastric contents quantitatively, and a CSA of 8.0 cm 2 might be a valid indicator of an empty stomach.

Prolonged heart rate-corrected QT (QTc) interval is frequently observed in subarachnoid hemorrhage (SAH). This study was conducted to determine the relationship between QTc interval and neurological outcome during the acute posthemorrhagic period after aneurysmal SAH. We studied 71 patients undergoing surgery who were admitted within 24 h after the onset of aneurysmal SAH. Standard 12-lead electrocardiography was performed on admission (T1) and at 1 and 7 days after operation (T2 and T3). QT intervals were corrected by heart rate according to the Fridericia formula. The Glasgow Coma Scale (GCS) score was calculated over the period T1–T3. Neurological outcome was assessed using the Glasgow Outcome Scale at hospital discharge. Among the 71 patients, 31 had an unfavorable neurological outcome. Although QTc interval prolongation improved in patients with a good outcome, QTc interval prolongation continued in patients with an unfavorable outcome. The areas under the receiver–operator characteristic curves showed that the QTc and GCS score at T3, and the Hunt and Hess grade were significant predictors of an unfavorable neurological outcome. The threshold value, sensitivity, and specificity for the QTc at T3 were 448 ms, 73% [95% confidence interval (CI), 68–78], and 93% (95% CI, 90–96), respectively. This study confirms that QTc interval prolongation continues in the SAH patients with an unfavorable outcome but that QTc interval prolongation improves in patients with a good outcome, suggesting that a QTc interval of more than 448 ms at 7 days after operation is a predictor of neurological outcome after SAH.

胃切除術,子宮摘出術,股関節手術を受けた患者をそれぞれの群に分け,麻酔導入直後の膀胱内貯留尿のカテコラミン(CA)濃度を対照値とし,術後7日間の早朝新鮮尿中CA濃度を測定し,その推移を比較検討した.尿中CA濃度は,回復室で一番高く,術後1日でほぼ対照値に近くなっているが,胃切除群の尿中ノルエピネフリン濃度のみが他の手術群に比べて,その回復が有意に遅延し,術後7日間にわたって対照値より高値を示した.一方,各群の尿中エピネフリン濃度は術後,逆に対照値に比較して有意に低値を示し,正常値とは有意差がなかった.以上の成績から,胃切除術では術後少なくとも7日間は交感神経の活性充進が持続することが示唆された.

The prolongation of QT interval and the increase of QT dispersion in the electrocardiogram are closely related with torsade de pointes and useful for the assessment of the risk of the anesthetic drugs and ischemic heart diseases.

BACKGROUND AND OBJECTIVE It is known that esmolol, a short-acting beta1-blocker, reduces anaesthetic requirement. In this study, we evaluated whether a low dose of landiolol, a new ultra-short-acting beta1-blocker, can reduce the sevoflurane requirement. METHODS Twenty-five patients undergoing hip surgery were randomly divided into two groups. Group A (n = 13) received landiolol (bolus injection of 0.031 mg.kg(-1) and continuous infusion at a rate of 0.01 mg.kg(-1).min(-1)). Group B (n = 12) received physiological saline. Landiolol and physiological saline were started before the induction of anaesthesia and continued until the end of anaesthesia. Anaesthesia was maintained with sevoflurane, 60% N(2)O and fentanyl. Sevoflurane concentration was controlled to keep the bispectral index at approximately 50. The end-tidal sevoflurane concentration and haemodynamics were measured during anaesthesia. RESULTS The average end-tidal sevoflurane concentration in group A was significantly lower than that in group B (1.2 +/- 0.30 vs. 1.8 +/- 0.3%, P < 0.01). Maximum values of systolic arterial pressure showed no difference between the groups, whereas the maximum value of heart rate in group A was significantly less than that in group B (61 +/- 10 vs. 76 +/- 14 beats min(-1), P < 0.05). CONCLUSION The results suggest that a low dose of landiolol significantly reduces the intraoperative sevoflurane requirement during sevoflurane/N(2)O/fentanyl anaesthesia in patients undergoing hip surgery.

腎機能障害のない予定手術患者149名を対象とした.NLAとGOE群に分け,回復室での尿中ノルエピネフリン(NE)とエピネフリン(Epi)を測定し,手術侵襲の大小について検討した.NLA下の尿NE, Epi濃度は対照値に比較してそれぞれ肝切除後8.6倍,20.8倍,大腸9.5倍,17.5倍,胃5.9倍,15.1倍,肺4.7倍,12.7倍,THRなどの整形外科手術4.5倍,10.0倍,胆嚢4.5倍,8.0倍,子宮2.4倍,7.3倍,甲状腺手術1.7倍,5.9倍の順に有意に増加した.一方,GOE下ではNE濃度の増加は著明ではなかった.回復室での鎮痛薬使用はNLAが5%に対してGOEは59%であった.以上より,(1)回復室での尿CA濃度から手術侵襲程度が比較できた.(2) NLAでは痛み刺激に無関係に副腎-交感神経系の活性亢進が示唆された.(3) GOEでは疼痛を訴えること,EpiがNEより高値を示したことから末梢神経線維の麻酔からの回復過程に差があると考えられる.

This study was carried out to evaluate the postoperative analgesic effects of preoperative intravenous flurbiprofen in patients undergoing arthroscopic rotator cuff repair under general anesthesia.We studied 44 patients who underwent an elective arthroscopic rotator cuff repair in a prospective, randomized, and double-blind fashion. The patients were divided into two groups. Group A (n = 22) received lipid emulsion 0.1 ml kg(-1) as a placebo, and group B (n = 22) received flurbiprofen 1 mg kg(-1) before the surgery. Intralipid or flurbiprofen was given intravenously 5 min before the surgery. General anesthesia was maintained with sevoflurane and nitrous oxide, and 10 ml of 0.75% ropivacaine was administered intraarticularly at the end of the surgery. Postoperative analgesia was supplied with intravenous 0.1 mg buprenorphine according to the patient's demand. The effectiveness of flurbiprofen's analgesic effect was measured by a visual analog scale (VAS) and by the amount of buprenorphine consumption at 0.5, 1, 2, 4, 6, 12, and 24 h after the surgery. Time to the first analgesic was also recorded.VAS in group B was significantly (P0.01) lower than that in group A during the first 6 h postoperatively. The amount of buprenorphine consumption in group B was also significantly (P0.01) less than that in group A within the first 2 h postoperatively. The time to first analgesic request in group B was significantly (P0.01) longer than that in group A.These results show that preoperative intravenous flurbiprofen facilitates the analgesic effect in the early postoperative period after arthroscopic rotator cuff repair.

It is known that an optimal dose of intrathecal morphine for analgesia after total hip arthroplasty in older patients is 0.1 mg. On the other hand, minidose intrathecal morphine (0.05 mg) is useful for analgesia after the transurethral resection of the prostate in elderly patients. We evaluated the postoperative analgesic effect of minidose intrathecal morphine after bipolar hip prosthesis in seniors (age 85 years or more) undergoing spinal anesthesia. Twenty seniors undergoing bipolar hip prosthesis under spinal anesthesia were randomly allocated to one of two groups. Group A (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, and group B (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, plus morphine, 0.05 mg. Pain, nausea, and itching were evaluated using a numerical rating scale, ranging from 0 to 10, at 0, 4, 8, 12, and 24 h after the operation. The values on the numerical rating scale for pain in group B were significantly lower than those in group A at 4, 8, and 12 h after the operation. There were no significant differences between the groups in the values on the numerical rating scale for nausea or itching throughout the time course of the study. No patient in either group showed hypoxemia or respiratory depression throughout the time course. The results show that minidose intrathecal morphine provides a good analgesic effect without side effects, and it would be an effective and safe procedure for bipolar hip prosthesis in seniors.

The change of oxygen consumption after withdrawal of sedation is controversial. We evaluated the changes of sedation depth, oxygen consumption and hemodynamics after withdrawal of midazolam sedation in the patients undergoing major abdominal surgery.We evaluated 18 patients after major abdominal surgery. Midazolam was used for intravenous sedation after admission to the ICU. Midazolam was administered at a bolus dose of 0.1 mg kg(-1), followed by continuous infusion at 0.04 mg kg(-1) hr(-1), which was adjusted every 2 hrs to achieve a desired level of sedation of 4 on Ramsay sedation scale (RSS). After about 14 hours of sedation, we stopped the infusion of midazolam. From that time, we measured systolic and mean arterial pressure, heart rate, minute volume and oxygen consumption, and evaluated RSS every 5 minutes for 1 hour. We evaluated RSS as sedation depth, oxygen consumption index (V(O2)I) and rate pressure product (RPP=systolic arterial pressure x heart rate) as hemodynamic parameters.RSS significantly decreased gradually, but the other parameters including V(O2)I and RPP were unchanged.After withdrawal of midazolam sedation in the patients undergoing major abdominal surgery, the sedation depth became lighter, but V(O2)I and RPP were unchanged.

Adequate volume therapy is essential for stable hemodynamics and sufficient urinary output perioperatively. Hydroxyethyl starch (HES) has been reported to attenuate the microvascular hyperpermeability which occasionally occurs in surgical patients. This study was carried out to evaluate the effect of low-molecular-weight HES on the urinary microalbumin/creatinine ratio (MACR), a marker of microvascular permeability, in surgical patients.In a prospective, controlled, and randomized clinical trial, 21 patients undergoing abdominal surgery were divided into two groups. Group HES (n = 10) received HES at 2 ml x kg(-1) x h(-1) during surgery and at 1 ml x kg(-1) x h(-1) after surgery, and additionally they received acetated Ringer's solution (AR) at a rate to keep central venous pressure (CVP) 5 mm Hg. Group AR (n = 11) received AR at a rate to keep CVP at 3-5 mmHg. MACR, soluble intercellular adhesion molecule-1 (sICAM-1), and urinary output were measured intermittently in the perioperative period.MACR was significantly increased during surgery in both groups. There was no significant difference in MACR between the two groups throughout the study period. The serum concentration of sICAM-1 decreased during surgery in both groups, and that in group HES was significantly lower than that in group AR at the end of surgery. Postoperative urinary output in group HES was greater than that in group AR. The intensive care unit (ICU) stay in group HES was shorter than that in group AR.Although low-molecular-weight HES does not improve microvascular hyperpermeability, the expansion of the intravascular volume by HES results in higher urinary output in the postoperative period than that seen with crystalloid solution. The lower concentration of sICAM-1 after surgery may be due to hemodilution.